Kaiser Permanente Center for Health Research, Portland, OR; Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR.
Kaiser Permanente Center for Health Research, Portland, OR.
Am J Obstet Gynecol. 2021 Jan;224(1):62.e1-62.e13. doi: 10.1016/j.ajog.2020.07.029. Epub 2020 Jul 18.
Genitourinary symptoms are common in postmenopausal women and adversely affect the quality of life. National surveys and data collected from our healthcare system indicate that postmenopausal women with the genitourinary syndrome of menopause often fail to receive appropriate diagnosis or treatment.
To promote greater detection and treatment of the genitourinary syndrome of menopause, we created and tested a clinician-focused health system intervention that included clinician education sessions and a suite of evidence-based electronic health record tools.
Using a cluster-randomized design, we allocated primary care (16) and gynecology (6) clinics to the intervention or control group. From September to November 2014, we provided training about the diagnosis and treatment of genitourinary syndrome of menopause in face-to-face presentations at each intervention clinic and in an online video. We developed clinical decision support tools in the electronic health record that contained an evidence-based, point-of-care knowledge resource, a standardized order set, and a checklist of patient education materials for the patient's after visit summary. The tools aimed to facilitate accurate diagnostic coding and prescribing (SmartSet, SmartRx) along with relevant patient information (SmartText). Clinicians who only performed visits at control clinics received no training or notification about the tools. Our primary outcome was vulvovaginal diagnoses made at well visits for women at the age of 55 years and older from November 15, 2014 to November 15, 2015. We also assessed urinary diagnoses, vaginal estrogen prescriptions, and use of the electronic tools. There was departmental support for the intervention but no prioritization within the healthcare system to incentivize change.
In the 1-year period, 386 clinicians performed 14,921 well visits for women at the age of 55 years and older. Among the 190 clinicians who performed well visits in the intervention clinics, 109 (57.4%) completed either in-person or online educational training. The proportion of visits that included a vulvovaginal (7.2% vs 5.8%; odds ratio, 1.27; 95% confidence interval, 0.65-2.51) or urinary diagnosis (2.5% vs 3.1%; odds ratio, 0.79; 95% confidence interval, 0.55-1.13) or vaginal estrogen prescription (4.5% vs 3.7%; odds ratio, 1.24; 95% confidence interval, 0.63-2.46) did not differ between study arms. There was a significant interaction for primary care and gynecology, which revealed more vulvovaginal diagnoses by gynecology but not primary care intervention clinics (odds ratio, 1.63; 95% confidence interval, 1.15-2.31), but there was no significant interaction for prescriptions. Clinicians in the intervention clinics were more likely to use decision support tools than those in control clinics-SmartSet (22.2% vs 1.5%; odds ratio, 18.8; 95% confidence interval, 5.5-63.8) and SmartText for patient information (38.0% vs 24.4%; odds ratio, 1.91; 95% confidence interval, 1.10-3.34). A per-protocol analysis revealed similar findings.
Overall, the intervention did not lead to more diagnoses or prescription therapy for postmenopausal genitourinary symptoms but did result in greater distribution of patient information. Gynecology clinicians were more likely to address genitourinary symptoms generally and were more likely to make a vulvovaginal diagnosis after the intervention. Further efforts for improving care should consider ongoing clinician education beginning with enhanced menopause curricula in residency training. Additional interventions to consider include greater access for postmenopausal women to gynecologic care, addressing treatment barriers, and development of national performance metrics.
泌尿生殖系统症状在绝经后妇女中很常见，会对生活质量产生不利影响。国家调查和我们医疗保健系统收集的数据表明，患有绝经后泌尿生殖系统综合征的女性往往无法得到适当的诊断或治疗。
为了提高绝经后泌尿生殖系统综合征的检测和治疗率，我们创建并测试了一项以临床医生为重点的卫生系统干预措施，其中包括临床医生教育课程和一套基于证据的电子健康记录工具。
我们采用了群组随机设计，将初级保健（16 个）和妇科（6 个）诊所分配到干预组或对照组。2014 年 9 月至 11 月，我们在每个干预诊所进行了面对面的培训，还在在线视频中提供了关于绝经后泌尿生殖系统综合征的诊断和治疗的培训。我们在电子健康记录中开发了临床决策支持工具，其中包含基于证据的即时护理知识资源、标准化医嘱集和患者就诊后总结的患者教育材料清单。这些工具旨在促进准确的诊断编码和处方（SmartSet、SmartRx）以及相关的患者信息（SmartText）。仅在对照组诊所进行就诊的临床医生没有接受培训或收到有关工具的通知。我们的主要结果是在 2014 年 11 月 15 日至 2015 年 11 月 15 日期间，为 55 岁及以上女性的就诊时做出的外阴阴道诊断。我们还评估了尿诊断、阴道雌激素处方和电子工具的使用情况。该干预措施得到了部门的支持，但在医疗保健系统中没有优先级来激励变革。
在为期 1 年的时间里，有 386 名临床医生为 55 岁及以上的女性进行了 14921 次就诊。在进行干预诊所就诊的 190 名临床医生中，有 109 名（57.4%）完成了现场或在线教育培训。包括外阴阴道（7.2%对 5.8%；优势比，1.27；95%置信区间，0.65-2.51）或尿诊断（2.5%对 3.1%；优势比，0.79；95%置信区间，0.55-1.13）或阴道雌激素处方（4.5%对 3.7%；优势比，1.24；95%置信区间，0.63-2.46）的就诊比例在研究组之间没有差异。初级保健和妇科之间存在显著的交互作用，这表明妇科干预诊所的外阴阴道诊断更多，但初级保健诊所没有（优势比，1.63；95%置信区间，1.15-2.31），但处方没有显著的交互作用。干预诊所的临床医生比对照组诊所更有可能使用决策支持工具-SmartSet（22.2%对 1.5%；优势比，18.8；95%置信区间，5.5-63.8）和 SmartText 用于患者信息（38.0%对 24.4%；优势比，1.91；95%置信区间，1.10-3.34）。一项符合方案分析显示了类似的发现。
总体而言，该干预措施并未导致更多的绝经后泌尿生殖系统症状的诊断或处方治疗，但确实增加了患者信息的分布。妇科临床医生更有可能普遍解决泌尿生殖系统症状，并且在干预后更有可能做出外阴阴道诊断。进一步改善护理的努力应考虑从增强居住培训中的更年期课程开始，对临床医生进行持续教育。其他需要考虑的干预措施包括为绝经后妇女提供更多的妇科保健机会、解决治疗障碍以及制定国家绩效指标。
